Burns

Notes
  • Burns are among the leading causes of morbidity globally causing prolonged hospitalization, disfigurement, disability, stigma and rejection.
  • When burn covers more than 25% of the body surface area there is rapid loss of plasma as well as possibilities of endotoxaemia.
  • Causes of burns include: heat (hot surfaces, hot liquids or flames), chemicals, irradiation, friction, sunburns and electrical accidents.
  • Evaluation of the surface area of burn in adults is done using Wallace Rules of Nine where the body surface area is assigned the following values: left arm 9%, right arm 9%, head 9%, chest 9%, abdomen 9%, back 18%, left leg 18%, right leg 18% Groin 1%. This rule is not applicable to children.
  • Evaluation of the surface area of burn in children: anterior head 9%, posterior head 9%, anterior torso 18%, posterior torso 18%, anterior leg, each 6.75%, posterior leg, each 6.75%, anterior arm, each 4.5%, posterior arm, each 4.5% and genitalia/perineum 1%.
  • Evaluation of the surface area of burn in infant below 10kg: head and neck 20%, anterior torso 16%, posterior torso 16%, leg, each 16% arm, each 8% genitalia/perineum 1%

##There are 3 degrees of burns:

  • 1st degree burn involving only epidermis
  • 2nd degree burn involving epidermis and part of dermis
  • 3rd degree of burn involving all layers of skin and subcutaneous tissues
  • Statistics: annual death rate due to burn globally- 265 000 (mainly in the low resource settings); number of people globally with burns in 2004 that required clinical care: 11 million: burns are the 11th leading cause of death of children aged 1-9 yrs; burns are the 5th most common cause of non-fatal childhood injuries; 80 to 90% of burns occur at home.
Symptoms
  • Blisters pain
  • Peeling skin
  • Red skin
  • Shock
  • Swelling white or charred skin
Diagnosis
  • Clinical review
Differential
  • Cellulitis toxic
  • Epidermal necrolysis
Prevention
  • Strengthening and implementation of the national policies on prevention and treatment of burns.
  • Promote the installation of smoke detectors, fire extinguishers, sprinklers and fire escape routes.
  • Promote use of safe cooking stoves as well as safe fuels.
  • First Aid training of the population on burns
Management

##Immediate care in the health institution include ensuring that the:

  • Airway is clear by either suctioning of oral airway or endotracheal intubation or as tracheostomy
  • Breathing is satisfactory. Oxygen may be given by mask.
  • Circulatory system is functional by employing such measures as administration of the IV fluids. Since the blood transfusion may be required, do the blood grouping and matching.

(Remember ABC)

  • Tetanus toxoid is administered.
  • Analgesics are given

##Hospital admission criteria for burn patients:

  • 10 - 25% burn to be admitted in general ward
  • ≥25% burn to be admitted in the special burn unit.
  • Pre-existing diseases e.g. hypertension and diabetes
  • Chemical, inhalational and electric burns
  • Joints and associated tissues
  • Face and neck burns
  • Hand and feet burns
  • Perineum

## IV fluid administration  in burn patients:

  • Administration of IV fluids is critical for the survival of admitted burn patients
  • In case of collapsed peripheral veins, venous cut-down (mainly saphenous) is done and catheter is inserted for IV fluids
  • Parkland's burn formula (4 mL of IV fluid/kg of body weight / per % of burn using total body surface area, TBSA) is used to determine the amount of fluids to administer to a patient following a burn. It is most useful during the first 24 hrs of fluid resuscitation with second degree or greater burns.
  • Generally, half of the IV fluid required is administered in the first 8 hrs while the second requirement is administered in the next 16 hrs.
  • Since pregnant women (with about 50% increase in the intravascular fluid volume) are more proned to extensive fluid loss, Parkland's burn formula is not applicable in their case. However, they can safely be administered with the volumes of fluid that are double the calculated values from Parkland's burn formula.
  • Ringer’s lactate and Hartmann's solution (NaCL, KCL, CaCl2 and Sodium Lactate) are the IV fluids of choice. Normal saline can be used as well.
  • Monitor vital signs, urine output (1-2mL/kg/hr) and packed cell volume

## Basic care of burn patients in hospitals

  • The wound must be cleaned with antiseptics (or normal saline or water).
  • Apply silver sulfadiazine cream or any other antiseptics
  • Using moist plastic bag on the burnt hands and feet
  • Placing the patient in the burn cage (cradle) if necessary.
  • Basic nursing care
  • Surgical debridement of burnt or dead tissues
  • Skin grafting of extensive burns

##Management of circumferential burns

  • In case where a burn leads to burn-induced compartmental syndrome, escharotomy is recommended. This is particularly useful in cases of 3rd degree burns.
  • Soon after the 3rd degree burn the underlying tissues are rehydrated. Due to the eschar's loss of elasticity, the expansion of the rehydrated tissues is restricted resulting in impaired circulation to the tissues distal to the wound.
  • To release this pressure build-up, an escharotomy is performed. In this operation, the burnt skin is incised down to the subcutaneous fat and into the healthy skin that can be 1cm deep.

## Management of inhalational burns

  • It should be suspected in case of open fire or smoke

Manage with;

  • Oxygen
  • Humidified air
  • Bonchodilators
  • Intubation (when indicated)
  • Antibiotics

## Management of electrical  burns

  • Electrocution mostly arises from low voltage accidents. High voltage tends to cause tissue destruction (especially)
  • Electric shock causes cardiac arrhythmias and muscle spasm.
  • Treatment includes synchronized electrical cardioversion or pharmacologic cardioversion (chemical cardioversion). In these treatments tachycardia or cardiac arrhythmia due electrocution are converted to a normal rhythm by use of electricity or antiarrhythmic agents (such as amiodarone, diltiazem, verapamil and metoprolol).
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